Inpatient care and treatment - virtual capacity: interview findings

Conclusion

This report provides insight into how VC is operating in Scotland. The interviews highlight the important roles local innovators have played, although this bottom-up approach has resulted in variable implementation and a lack of equity of access across Scotland.

Participants reflected that the recent national focus has helped to accelerate service development. With the advent of the Covid-19 pandemic came a need to find alternative ways of providing hospital level care outwith the acute setting. National funding has enabled expansion, though questions remain about funding sustainability, which also has wider consequences for the workforce. Participants underlined the need for sustainable funding to develop the pace and scale of change, as well as a culture that fosters new ways of working, a skilled workforce, and buy-in from strategic decision-makers and other key stakeholders.

The evidence review examined literature on the effectiveness of VC and patient experience. Overall, there is encouraging evidence for the implementation of VC across the UK. However, VC is still developing and more empirical evidence is required to understand if it works and in what circumstances.

There is evidence from the literature review that patients are broadly satisfied with VC services. Patients valued receiving care and treatment in the comfort and familiarity of their own home environment, alongside the reduced disruption to their everday lives and routines. Safety, and issues related to transportation method and cost, were however cited as concerns.

VC services were noted to have the potential to alleviate pressure on hospitals, though the extent of this varies according to what outcomes are being measured and the associated pathway in question. Hospital at Home and OPAT save hospital bed days in Scotland, whilst research on monitoring Covid-19 via pulse oximetry is inconclusive and no published evidence was found for respiratory services.

The literature demonstrates that cardiac and respiratory VC services reduce hospital readmissions. However, systematic review evidence of OPAT services in the UK, Europe, and North America is inconclusive, although it should be noted that OPAT is designed to cure infections as opposed to explicitly reduce readmissions. Furthermore, RCT evidence reported increased readmissions from hospital level care for those receiving Hospital at Home at one month follow up, but not at six months, whilst service evaluations reported mixed findings. This may be explained by a lack of available overnight care and the clinical needs of people using Hospital at Home services. This was reflected in the interviews, with it being noted that readmissions are common for people using Hospital at Home services, due to high acuity, as opposed to the intervention itself.

The ability of VC to reduce length of stay depends on what is being measured. VC services were effective at reducing length of treatment for respiratory conditions and COVID-19. Evidence from a large RCT in the UK shows that Hospital at Home can support earlier discharge from hospital (Singh et al, 2022). However, length of treatment can be slightly longer for people receiving Hospital at Home (in the home/community setting) compared to inpatients, though statistical significance was not reported (Shepperd et al, 2021).

Recommendations

The priorities we recommend moving forward are:

• Further research to evaluate what works for whom and in what circumstances for VC in Scotland.
• Consistency in how effectiveness is defined and measured across the pathways to allow comparisons to be made quickly and on a regular basis.
• Consideration of other metrics to evaluate the pathways (i.e. what outcomes do patients and their relatives/carers perceive as important?).
• Further research to explore the extent, nature, and impact of inequities in access to VC.
• An economic evaluation of the financial costs of virtual capacity to understand if treating people at home rather than hospital is economically beneficial.
• Given the shift in treatment from the hospital to the home setting, an evaluation of the impact and experiences of informal carers/families.
• An evidence review of international evidence on VC that includes safety as an outcome measure.